Patient Frailty Associated with Increased Morbidity for Common Ambulatory Surgeries in Older Adults

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A new research study shows that patient frailty should be assessed in preoperative planning for surgery in older adults, even for common ambulatory general surgery operations. The study, led by principal investigator and lead author, Carolyn D. Seib, M.D., MAS, a general and endocrine surgeon at UCSF, wasreported on in the journal JAMA Surgery and highlighted by the NY Times in a subsequent article.

Importantly, the study found that frailty is more closely associated with the risk of complications than chronological age. It has implications for both treatment planning and informed consent for older adults undergoing otherwise routine ambulatory surgery, but who are deemed frail. Dr. Seib underscored the significance of the study's findings.

Our JAMA Surgery study expands on the work of Dr. Emily Finlayson, director of the UCSF Center for Surgery in Older Adults and co-author, that evaluated survival and functional status after colon cancer surgery, finding that nursing home residents experienced substantial and sustained functional decline after surgery. While it is fairly intuitive that patient frailty can adversely impact outcomes for major operations like colon resections, our study shows that frailty contributes to morbidity even for common ambulatory operations that patients and providers often treat as routine. Thus, we should take frailty into account for any operation, big or small, and make screening for frailty a routine component of preoperative clinic visits. Surgeons will then be able to more accurately relay surgical risk to patients and their families during informed consent discussions, and ensure that the proposed surgical intervention is consistent with the treatment plan. It is essential that we provide specialized care tailored to the needs of the older adult to improve surgical outcomes and limit morbidity.

Frailty, Dr. Seib notes, involves decreased physiological reserve that determines how patients will respond to physical stress. In fleshing out this concept, she told the NY Times:

Surgery brings plenty of that, said Dr. Carolyn Seib, a general and endocrine surgeon at the University of California, San Francisco. The effects of anesthesia and inflammation, the risk of blood clots or infection, muscle weakness caused by days in bed — all can take a toll.

“The more frail a patient is, the higher the risk of complications,” Dr. Seib said.

Researchers have shown that after major operations — including cardiac and colon cancer surgery and kidney transplants — frail older patients are more prone than others to longer hospital stays, being readmitted within a month of a procedure and winding up in nursing homes after they’re discharged.

They’re also more likely to die.

But a study that Dr. Seib and her colleagues published in JAMA Surgery this month shows that frail seniors face higher complications even after ambulatory surgery, outpatient procedures often considered routine.

Yet when the researchers looked at 141,000 patients over age 40 in a national surgical database, they found that serious complications were two to four times higher in patients with moderate to high frailty, although complication rates overall were low (1.7 percent, with .7 percent experiencing serious complications).

“We have to take frailty into account for any operation, big or small,” Dr. Seib said. Although surgeons increasingly screen for frailty, “I wouldn’t say it’s routine yet,” she added.

So she and other researchers recommend that before an operation, patients and families ask: Is my mother showing signs of frailty? Should we do an assessment that indicates how frail she might be?